What is your Physical Address?

If your job offers health insurance and you reject it, you will be liable to pay back your tax credit for your Marketplace plan at the end of the year!

I hereby grant my permission for Amir Zamani to act as my health insurance agent for both myself and my entire household, if applicable. This permission is specifically for the purpose of enrolling in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By agreeing to this arrangement, I authorize the aforementioned agent to access and utilize the confidential information provided by me, whether in writing, electronically, or via telephone, solely for one or more of the following purposes:

1. Searching for an existing Marketplace application.

2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan, or other government insurance affordability programs, such as Medicaid and CHIP, or advance tax credits to assist in paying for Marketplace premiums.

3. Providing ongoing account maintenance and enrollment assistance, as required.

4. Addressing inquiries from the Marketplace regarding my Marketplace application.

5. In the event that I already have a Marketplace plan, granting permission to switch to a more suitable plan if available. If I am already on the optimal plan, I request that the agent take over as my agent of record from this point forward, unless notified of any changes.

I understand that the agent will not utilize or disclose my personally identifiable information (PII) for any purposes other than those explicitly enumerated above. The agent will take necessary measures to ensure the confidentiality and security of my PII when collecting, initiating, and utilizing it for the aforementioned purposes. I affirm that the information I have furnished for my Marketplace eligibility and enrollment application is accurate to the best of my knowledge. I am aware that I am not obligated to provide additional personal information about myself or my health to my agent beyond what is necessary for the application for eligibility and enrollment.

I also understand that my consent remains in effect until I choose to revoke it, and I retain the right to revoke or notify my consent at any time by sending an email, text, or making a phone call to the following:

Name of Primary Writing Agent: Amir Zamani

Agent National Producer Number: 20731634

Phone Number: 702-353-3811

Email Address: [email protected]

Expiration Date: 11/01/2026

I acknowledge and understand the following:

1. I must provide accurate information for eligibility and may need to provide proof.

2. If I'm enrolled in Marketplace coverage and later found to have other qualifying health coverage (e.g. Medicaid, Medicare, CHIP, job-based plan), my Marketplace plan will be terminated automatically.

3. I permit the Marketplace to use my income data for 5 years to determine my eligibility for assistance.

4. I'm not eligible for a premium tax credit if I have other qualifying health coverage.

5. I must inform the Marketplace if I become eligible for other coverage to avoid repayment of the premium tax credit.

6. I must file a federal income tax return for the 2025 tax year.

7. If I’m married at the end of 2025, I must file a joint income tax return with my spouse.

8. No one else will be able to claim me as a dependent

9. I understand, this does not constitute tax advice, and I should consult a tax advisor for tax-related matters.

10. I consent to receive electronic notices and use electronic signatures during enrollment.

11. I confirm I'm authorized for the provided phone number and agree to receive marketing calls/messages.

12. Amir Zamani will use my information to complete and submit the Marketplace application on my behalf

13. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.